Wednesday, August 25, 2010

Problems with modern healthcare - Chap 4 from Dr Nadkarni's book

Medical practice or the health-care delivery system is also an industry and rules of industry must apply to the healthcare system. This is not realized by most of the people. Neither the patient nor the political and social leadership of the citizens is willing to accept this fact. If at all, they accept this fact most reluctantly. 'Every life is precious and cannot be counted in terms of rupees', is the common statement which is still accepted by almost all sections of the society. However, this is not true. This is borne out by the compensations given by courts or compensation boards in various cases of loss of limb or life. Every life is valued differently and that is a fact. As in every industry, money must be spent to create the infrastructure and employ professionals to run the services and the services must bring returns enough to continue the services and, if possible, to expand the services. The service rendered here is health service i.e. the service that makes a person disease free. Can this be calculated in terms of money? The answer is both 'Yes' and 'No' Even though the exact quantum in terms of money gained by a patient when he is cured of his disease cannot be measured easily, the overall effect on the society and its productivity can be measured. A person made healthy certainly can work better and this results in an increase in his productivity and increase in the general domestic product - G.D.P. of the country. That addition to the society, quantifiably or qualitatively, defines the total returns to the society by the actual treatment given under the health-care delivery system. Even for children the health and education produce better citizens and therefore, betterproductivity when they become adults. This is the generalization of the value of health delivery system. It does not help to define the exact quantum of charges to be levied to each patient for the different services he or she gets, but surely we can define the total budget to be spent on health. Also this itself proves the fact that no treatment can be free. It has to be paid for by somebody. In the so called 'free' hospitals run by government or by public organizations or by large private corporate industries, the payment is done not by the patient himself but is paid by the organization which creates the health care facility. For public or private sector industries, the workers under them are contributing a great deal to the wealth created in their respective industries and the management merely takes out a chunk of that money to provide them good health care services. Therefore, indirectly, it is the worker who pays for his health care service. For government and municipal hospitals, the patients get free treatment but as I said earlier no treatment can be free.

Therefore, the money required for creating such a health service is collected from the whole mass of people living in that particular state or city as some taxation or the other. It is the tax money paid by entire population, a part of which goes for the health care system created by government / municipality but nobody knows the inter-relationship between the money collected and money spent. Thus the money spent on health becomes un-correlatable to the money collected through taxes. For example, a major bulk of the taxation Mumbai Municipal Corporation collects comes from octroi which is the tax collected for every kind of good brought into the city. This has no correlation to the health care system and yet a lot of that money is spent on the health care service by Mumbai Municipal Corporation. It is not realized that a huge structure has been established for collecting the money, accounting for it and then planning the redistribution of that money to the various services / schemes of the municipality / government. This infrastructure itself eats away nearly 60 percent of the money collected. Part of the remaining 40 percent is allotted to the health care system but it is a well known fact that, out of this, a large percentage is lost in corruption. The percentage of such a loss could be anything from 20 percent to 50 percent. Thus, out of the total money, the population has contributed as taxation, hardly 20 percent reaches them as health care service. None other than our former prime minister Shri Rajiv Gandhi stated in one of his speeches that the citizen gets only 11 paise worth service out of a rupee that he pays in tax. However the poor common man thinks that these taxes are paid by the rich and he gets free treatment and, therefore, there is nothing wrong about it. This is the most fallacious concept the common man has. In fact, 80percent of the taxation comes from indirect taxation and, therefore, ultimately he alone pays all these taxes. When he buys vegetables or rice or cereal, it is he who pays the tax on the truck and lorry that brings these articles. It is he who pays the taxes that are levied on the merchant for his grain shop. The ultimate price of the vegetable could have risen three times or four times from what its price was in the village. It is surprising that social and political leaders are not bringing this to light to all the people at large. I can understand politicians-they have too many stakes in the present system. However I am deeply surprised that none of the N.G.O. and social workers / journalists sincerely interested in the welfare of the poor hardworking common man are not highlighting this aspect and not warning them against 'Free Government Schemes.' The politicians of the country continue to tax more and more, after promising the common citizen more and more 'free' services. There are other disadvantages to which I will allude to later. For the time being what I am emphasizing is that the health care system, in fact, is an industry and money must come in from some source to be spent on the infrastructure, the professionals and the consumables to be used in the health care system.

In the present system, 'free health care ' in government hospitals is the costliest way. The people are paying through their noses in return for very poor service. In the private sector, the patient directly pays for the service he gets. As mentioned earlier the charges are not regulated butdepend on the whims and fancies of the doctors and the hospitals. The charges vary depending on the economic status of the patient and the reputation of the health professional or hospital. So far, the hospitals and the doctors have not made any worthwhile efforts to regulate the charges. The principles adopted by most of the hospitals is what was termed in U.S.A. as 'cost plus'-which means whatever the costs incurred by the hospital or the doctor, additional profits are added as per their own calculation and this amount is what the patient has to pay. There were no efforts to find out whether the cost can be reduced by better administrative system or by more appropriate equipments at lesser cost. Thus, here too, the patients have to pay through the nose for the services that they get. With more and more equipments used in the modern days and with high salaries to the professionals working on these equipments, the price of health care is mounting steeply and is now going nearly out of hands of the common man or even an upper middle class family. Secondly it is extremely difficult for a common man to collect suddenly and pay the sum in thousands and lakhs and he has to either sell family jewellery or some property`or take a huge loan to fulfil the health-care obligations. In a recent study about two years back in U.P. a social Institute of Science observed that if any patient got admitted and treated for any serious illness in any hospital private or public in U.P., 40% of them went below the poverty line due to the expenses incurred during the full course of his treatment. Though no such study has appeared in the state of Maharashtra, some authors believed that the figure for Maharashtra could not be less that 35% However, the system of unregulated private practice continues and in fact covers nearly 60% of the total urban health care system in the state. A few are lucky that their employers take care of their health expenses as mentioned earlier. About 25% of the total population is thus protected against the financial burden of the health carein these organized sectors. The bulk of them are government employees or corporate industrial workers. A new system is coming up of late i.e. the scheme of health insurance. Just like a person can insure for life, he can now insure for his health and the health of his family. Not every person falls ill. Presuming that one out of 250 falls ill in a given year and, therefore, needs to pay for the health service, it can be clearly calculated that he will have to pay hardly 1/250 of the total bill, if all the 250 persons have insured for their health. If the cost and profit of the company which provides such service was also taken into account, it could be 1 / 150 or 1 / 200 of the total cost. Therefore, on this presumption, if the total bill of a patient who requires the hospital service is Rs. 1,00,000/- (One lac), he will be paying only about Rs. 650/- or Rs. 500/- annually for such service. (Rs. 1,00,000/- divided by 150 or 200)]. Undoubtedly this is an excellent scheme and the government and healthcare Institutions must make maximum efforts to encourage maximum number of people to adopt the Health Insurance Scheme. In Europe and in U.S.A. there is hardly a citizen who is not covered by health insurance scheme. However, in actual practice. The health insurance scheme is not as rosy as is pictured above. This aspect of insured health-care service will be dealt with in detail later. However basically it is a good concept to pay collectively for the health service and reap the benefit individually as and when required. Hence, the same thing was sought to be achieved through taxes (as health cess) in a completely nationalized health care system. This has been tried in England and Sweden. Even though the common man is guaranteed free treatment with the help of minimum health cess in England, the system is extremely faulty. It has become a white elephant for the government and the public at large are not very happy. Appointment for an operation could be after a year or more-if you live. Obviously coming to the other extreme of nationalized health service through taxation money does not seem to help. The nationalized health service scheme seems to be working very well in a few very advanced socialistic states like Sweden. In Sweden the health-care-system covers from 'womb to Tomb'. In Sweden, a woman gets a special allowance from the government when she becomes pregnant, and when a person dies, he / she (i.e. the relatives) gets special allowance for the final disposal of the body. Everything is taken care of. However it must be remembered that Swedish citizens pay extremely heavy taxes amounting to more than 40% of their income (I am told). It is relatively a small state and it is almost totally non-corrupt. Both the community at large and the government machinery have an extremely high degree of honesty and integrity. That is why, the scheme of nationalized health services seems to be working satisfactorilyAll these patterns of expenditures and incomes have been discussed merely to show that while considering the most suitable health care systems for our country, we will have to realize that money must come in for being spent on health care.

Money in = Money out in the Modern Health Care System

The advanced system of health-care has created two fold effects. Today the medical professional knows much more about exact physiology of the body. He has an extremely detailed knowledge of the chemical processes that occur in every organ during its functioning. With equipments like C.T. scan, Ultra Sound or M.R.I. he can penetrate into the deepest part of the body and see the structural changes, if any, that could have distorted any organ in the body. There are umpteen number of tests like P.C.R. or enzyme studies or tumour markers by which minutest amount of pathological substance can be detected and thereby early diagnosis can be made - sometimes even before any symptoms have troubled the patient. Thus, there is no doubt that the disease can be diagnosed at an extremely early stage and can be treated much more accurately, thus giving patients maximum cure rate. However, most of these investigations need high technology and sophisticated equipment and the cost of investigations and the treatment becomes formidably high. This equipment cannot be operated by an ordinary worker and therefore, the workers need to be properly educated and need further specific training to operate these equipments. Naturally all of them have to be paid much higher salary than the average worker. This being an expanding field of science, the need of such skilled workers is equally high in the developed countries and therefore many of these trained workers easily migrate to the developed countries, leaving behind a great shortfall of such workers in our own country. That in turn makes it imperative for the hospital to give them increased pay scale. Costly equipment, costly workers and specially trained doctors (super specialists); naturally the treatment cannot be but expensive. It is a common practice of our political leaders to install such machines in some big hospitals and profess that the hospital must find ways of making these treatments cheaper and affording for the common man or that such treatmentsshould become available in the villages. The fallacy is apparent. This treatment could never be less expensive and can never reach the villages. Luckily such high cost treatment is not needed for many diseases and it has been proved by statistics that the treatment by such sophisticated equipments has not contributed much to the increase in average lifespan of the common man. Much more has been achieved by hygiene, better living standard and primary health care. These sophisticated equipments have undoubtedly been selectively useful to some individuals who suffer from previously incurable diseases and to whom modern management has given a much longer span of active life. In short, modern high-tech health care system is definitely very useful for a select few individuals who were previously incurable, but has very little impact on the society as a whole whose longevity has been only marginally increased by its modern techniques.